Pulmonary artery enlargement is associated with pulmonary hypertension and decreased survival in severe cystic fibrosis: A cohort study

Prognostic value of pulmonary artery diameter/aorta diameter ratio in patients with acute pulmonary embolism

BACKGROUND

The ratio of pulmonary artery diameter (PAD) to ascending aortic diameter (AoD) has been reported to be a prognostic marker in several lung diseases; however, the usefulness of this tool in patients with acute pulmonary embolism (APE) is unknown. Here, we aimed to determine the long-term prognostic value of the PAD/AoD ratio in patients with APE.

METHODS

A total of 275 patients diagnosed with APE at our tertiary care center between November 2016 and February 2022 were included in the study. The patients were divided into two groups according to the presence of long-term mortality and their PAD/AoD ratios were compared.

RESULTS

Long-term mortality was observed in 48 patients during the median follow-up of 59 (39-73) months. The patients were divided into two groups for analysis: group 1, consisting of 227 patients without recorded mortality, and group 2, consisting of 48 patients with documented mortality. A multivariate Cox regression model indicated that the PAD/AoD ratio has the potential to predict long-term mortality (HR: 2.9116, 95% CI: 1.1544-7.3436, p = 0.023). Analysis of the receiver operating characteristic curve revealed that there was no discernible difference in discriminative ability between the simplified pulmonary embolism severity index (sPESI) and PAD/AoD ratio (area under the curve [AUC] = 0.679 vs. 0.684, respectively, p = 0.937). The long-term predictive ability of the PAD/AoD ratio was not inferior to the sPESI score.

CONCLUSIONS

The PAD/AoD ratio, which can be easily calculated from pulmonary computed tomography, may be a useful parameter for determining the prognosis of APE patients.

CT-derived lung vessel morphology correlates with prognostic markers in precapillary pulmonary hypertension

BACKGROUND

While computed tomography pulmonary angiography (CTPA) is an integral part of the work-up in patients with suspected pulmonary hypertension (PH), there is no established CTPA-derived prognostic marker. We aimed to assess whether quantitative readouts of lung vessel morphology correlate with established prognostic indicators in PH.

METHODS

We applied a fully-automatic in-house developed algorithm for segmentation of arteries and veins to determine lung vessel morphology in patients with precapillary PH who underwent right heart catheterization and CTPA between May 2016 and May 2019. Primary endpoint of this retrospective study was the calculation of receiver operating characteristics for identifying low and high mortality risk according to the 3-strata risk assessment model presented in the current guidelines.

RESULTS

We analyzed 73 patients, median age 65 years (interquartile range (IQR): 54-76), female/male ratio 35/38, median mean pulmonary arterial pressure 37 mm Hg (IQR: 30-46), and found significant correlations with important prognostic factors in pulmonary arterial hypertension. N-terminal pro-brain natriuretic peptide, cardiac index, mixed venous oxygen saturation, and 6-minute walking distance were correlated with the ratio of the number of arteries over veins with vessel diameters of 6-10 mm (Spearman correlation coefficients ρ = 0.64, p < 0.001; ρ = -0.60, p < 0.001; ρ = -0.47, p = 0.005; ρ = -0.45, p = 0.001, respectively). This ratio predicted a low- and high-risk score with an area under the curve of 0.73 (95% confidence interval (CI): 0.56-0.90) and 0.86 (95% CI: 0.74-0.97), respectively.

CONCLUSIONS

The ratio of the number of arteries over veins with diameters between 6 and 10 mm is significantly correlated with prognostic markers in pulmonary hypertension and predicts low and high mortality risk.

Pathogenesis, clinical features, and phenotypes of pulmonary hypertension associated with interstitial lung disease: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative - Group 3 Pulmonary Hypertension

Pulmonary hypertension (PH) is a frequent complication of interstitial lung disease (ILD). Although PH has mostly been described in idiopathic pulmonary fibrosis, it can manifest in association with many other forms of ILD. Associated pathogenetic mechanisms are complex and incompletely understood but there is evidence of disruption of molecular and genetic pathways, with panvascular histopathologic changes, multiple pathophysiologic sequelae, and profound clinical ramifications. While there are some recognized clinical phenotypes such as combined pulmonary fibrosis and emphysema and some possible phenotypes such as connective tissue disease associated with ILD and PH, the identification of further phenotypes of PH in ILD has thus far proven elusive. This statement reviews the current evidence on the pathogenesis, recognized patterns, and useful diagnostic tools to detect phenotypes of PH in ILD. Distinct phenotypes warrant recognition if they are characterized through either a distinct presentation, clinical course, or treatment response. Furthermore, we propose a set of recommendations for future studies that might enable the recognition of new phenotypes.

Can Bioactive Food Substances Contribute to Cystic Fibrosis-Related Cardiovascular Disease Prevention?

Advances in cystic fibrosis (CF) care have significantly improved the quality of life and life expectancy of patients. Nutritional therapy based on a high-calorie, high-fat diet, antibiotics, as well as new therapies focused on CFTR modulators change the natural course of the disease. They do so by improving pulmonary function and growing BMI. However, the increased weight of such patients can lead to unwanted long-term cardiovascular effects. People with CF (pwCF) experience several cardiovascular risk factors. Such factors include a high-fat diet and increased dietary intake, altered lipid metabolism, a decrease in the level of fat-soluble antioxidants, heightened systemic inflammation, therapeutic interventions, and diabetes mellitus. PwCF must pay special attention to food and eating habits in order to maintain a nutritional status that is as close as possible to the proper physiological one. They also have to benefit from appropriate nutritional counseling, which is essential in the evolution and prognosis of the disease. Growing evidence collected in the last years shows that many bioactive food components, such as phytochemicals, polyunsaturated fatty acids, and antioxidants have favorable effects in the management of CF. An important positive effect is cardiovascular prevention. The possibility of preventing/reducing cardiovascular risk in CF patients enhances both quality of life and life expectancy in the long run.

Pulmonary artery enlargement: an independent risk factor for mortality in hospitalized COVID-19 patients

Objective

To assess whether baseline pulmonary artery diameter (PAD), obtained from Non-contrast non-gated computed tomography (NCCT), can be associated with COVID-19 outcomes.

Patients and Methods

This is a retrospective study of hospitalized COVID-19 patients admitted to Hôtel-Dieu de France university hospital (Beirut, Lebanon) between March 2020 and March 2021. PAD was measured on baseline NCCT. Various outcomes were assessed, including hospital length of stay, ICU admission, invasive mechanical ventilation, mortality, and post-covid functional scale (PCFS) status at discharge and at 2-month follow-up.

Results

465 patients had a baseline NCCT, including 315 males (67.7%) with a mean age of 63.7±16 years. Baseline PAD was higher in critically ill patients admitted to the ICU (mean difference 0.8 mm [95% CI 0.4-1.59 mm]) and those receiving invasive mechanical ventilation (mean difference 1.1 mm [95% CI 0.11-2.04 mm]). PAD at baseline correlated significantly with hospital length of stay (r = 0.130, p=0.005), discharge status (r=0.117, p=0.023) and with PCFS at 2-month follow-up (r=0.121, p=0.021). Moreover, multivariable logistic regression showed that a PAD ≥ 24.5 mm independently predicted in-hospital all-cause mortality remained unaffected in COVID-19 patients (OR 2.07 (95% CI 1.05 - 4.09)).

Conclusion

Baseline PAD measurement using NCCT can be a useful prognostic parameter. Its measurement can help identify early severe cases and adapt the initial management of hospitalized Covid-19 patients.

Role of cardiovascular computed tomography parameters and lungs findings in predicting severe COVID-19 patients: a single-centre retrospective study

Background

Results

Conclusions

Mucus Release and Airway Constriction by TMEM16A May Worsen Pathology in Inflammatory Lung Disease

Activation of the Ca²⁺ activated Cl⁻ channel TMEM16A is proposed as a treatment in inflammatory airway disease. It is assumed that activation of TMEM16A will induce electrolyte secretion, and thus reduce airway mucus plugging and improve mucociliary clearance. A benefit of activation of TMEM16A was shown in vitro and in studies in sheep, but others reported an increase in mucus production and airway contraction by activation of TMEM16A. We analyzed expression of TMEM16A in healthy and inflamed human and mouse airways and examined the consequences of activation or inhibition of TMEM16A in asthmatic mice. TMEM16A was found to be upregulated in the lungs of patients with asthma or cystic fibrosis, as well as in the airways of asthmatic mice. Activation or potentiation of TMEM16A by the compounds Eact or brevenal, respectively, induced acute mucus release from airway goblet cells and induced bronchoconstriction in mice in vivo. In contrast, niclosamide, an inhibitor of TMEM16A, blocked mucus production and mucus secretion in vivo and in vitro. Treatment of airway epithelial cells with niclosamide strongly inhibited expression of the essential transcription factor of Th2-dependent inflammation and goblet cell differentiation, SAM pointed domain-containing ETS-like factor (SPDEF). Activation of TMEM16A in people with inflammatory airway diseases is likely to induce mucus secretion along with airway constriction. In contrast, inhibitors of TMEM16A may suppress pulmonary Th2 inflammation, goblet cell metaplasia, mucus production, and bronchoconstriction, partially by inhibiting expression of SPDEF.

Association between pulmonary artery to aorta diameter ratio with pulmonary hypertension and outcomes in diffuse cystic lung diseases

To investigate the importance of pulmonary vascular measurements on computed tomography (CT) in predicting pulmonary hypertension (PH) and worse outcomes in diffuse cystic lung diseases (DCLDs).We conducted a cross-sectional study of patients with DCLDs. Patients underwent pulmonary function tests, a six-minute walk test (6MWT), chest CT, transthoracic echocardiography, and right heart catheterization. Pulmonary artery (PA) diameter and PA-ascending aorta ratio (PA-Ao ratio) were obtained from CT. Mean pulmonary artery pressure (mPAP) from right heart catheterization was correlated with tomographic, functional, and echocardiographic variables. The association between the PA-Ao ratio with outcomes was determined by Kaplan-Meier curves.Thirty-four patients were included (18 with pulmonary Langerhans cell histiocytosis and 16 with lymphangioleiomyomatosis, mean age 46 ± 9 years). Forced expiratory volume in the first second and lung diffusing capacity for carbon monoxide were 47 ± 20% and 38 ± 21% predicted, respectively. PA diameter and PA-Ao ratio were 29 ± 6 mm and 0.95 ± 0.24, respectively. PA-Ao ratio > 1 occurred in 38.2% of patients. PA-Ao ratio was a good predictor of PH. mPAP correlated best with PA-Ao ratio, PA diameter, oxygen desaturation during six-minute walk test, and echocardiographic variables. Patients with PA-Ao ratio > 1 had greater mPAP, and a higher risk of death or lung transplantation (log-rank, P < .001) than those with PA-Ao ratio ≤ 1.The PA-Ao ratio measured on CT scan has a potential role as a non-invasive tool to predict the presence of PH and as a prognostic parameter in patients with DCLDs.

Cardiovascular complications in cystic fibrosis: A review of the literature

Cystic fibrosis is a genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, leading to dysfunction of the CFTR protein. CFTR dysfunction leads to disease in the respiratory and gastrointestinal systems. Disorders of the cardiovascular system in individuals with CF are usually attributed to secondary effects from progressive lung disease. However, CFTR has been localized to vascular endothelium and smooth muscle, suggesting that CFTR dysfunction may directly impact cardiovascular function. As treatments for CF improve and life-expectancy increases, the risk of vascular disease may increase in prevalence related to primary and secondary CFTR dysfunction, chronic systemic inflammation, nutritional health and hyperglycemia in individuals with CF related diabetes. Here we review the available literature on CF and the cardiovascular system, examining the secondary effects and evidence for direct CFTR dysfunction in the heart, aorta, pulmonary vessels, and vasculature, as well as future directions and treatment options.

Enhancing care for individuals with advanced cystic fibrosis lung disease

While remarkable advances in cystic fibrosis (CF) care have led to improvements in survival and quality of life, many individuals with CF are living with advanced cystic fibrosis lung disease (ACFLD) and others will face continued disease progression and its associated complex treatments and choices. This review will provide a summary of recently published guidelines for ACFLD care and lung transplant referral and highlight ongoing work to enhance the care of those with ACFLD through improvements in medical and psychosocial care, palliative care, and care around lung transplantation.

The Association of CT-measured Cardiac Indices with Lung Involvement and Clinical Outcome in Patients with COVID-19

RATIONALE AND OBJECTIVES

Cardiac indices can predict disease severity and survival in a multitude of respiratory and cardiovascular diseases. Herein, we hypothesized that CT-measured cardiac indices are correlated with severity of lung involvement and can predict survival in patients with COVID-19.

MATERIALS AND METHODS

Eighty-seven patients with confirmed COVID-19 who underwent chest CT were enrolled. Cardiac indices including pulmonary artery-to-aorta ratio (PA/A), cardiothoracic ratio (CTR), epicardial adipose tissue (EAT) thickness and EAT density, inferior vena cava diameter, and transverse-to-anteroposterior trachea ratio were measured by non-enhanced CT. Logistic regression and Cox-regression analyses evaluated the association of cardiac indices with patients' outcome (death vs discharge). Linear regression analysis was used to assess the relationship between the extent of lung involvement (based on CT score) and cardiac indices.

RESULTS

Mean (±SD) age of patients was 54.55 (±15.3) years old; 65.5% were male. Increased CTR (>0.49) was seen in 52.9% of patients and was significantly associated with increased odds and hazard of death (odds ratio [OR] = 12.5, p = 0.005; hazard ratio = 11.4, p = 0.006). PA/A >1 was present in 20.7% of patients and displayed a nonsignificant increase in odds of death (OR = 1.9, p = 0.36). Furthermore, extensive lung involvement was positively associated with elevated CTR and increased PA/A (p = 0.001).

CONCLUSION

CT-measured cardiac indices might have predictive value regarding survival and extent of lung involvement in hospitalized patients with COVID-19 and could possibly be used for the risk stratification of these patients and for guiding therapy decision-making. In particular, increased CTR is prevalent in patients with COVID-19 and is a powerful predictor of mortality.

Pulmonary artery to ascending aorta ratio by echocardiography: A strong predictor for presence and severity of pulmonary hypertension

BACKGROUND

The pulmonary artery (PA) to ascending aorta diameter ratio (PA:A) has been evaluated in numerous studies analyzing cardiac magnetic resonance (CMR) and computed tomography (CT) data. Previously, no transthoracic echocardiography (TTE) cutoffs have been published. We sought to evaluate (1) the feasibility to image the pulmonary trunk in a prospective cohort, and (2) the ability of PA:A derived by TTE to predict pulmonary hypertension (PH).

METHODS

We performed a post-hoc analysis of a prospectively recruited consecutive cohort of patients referred to our tertiary center cardiology department due to suspicion for PH. Invasive hemodynamic assessment and quasi-simultaneous TTE was performed in all participants.

RESULTS

A total of 84 patients were included in the analysis, median age was 70.5 years (IQR 58-75), 46 (55%) were female. The PA was significantly wider in the PH group (28mm vs. 22.5mm, p<0.001) with a resulting median PA:A of 0.84 vs. 0.66 (p<0.001). Both PA diameter (r = 0.524 and r = 0.44, both p<0.001) and PA:A (r = 0.652 and 0.697, both p<0.001) significantly correlated with mPAP and with PVR, respectively. Area under the curve for the detection of PH was 0.853 (95%CI 0.739-0.967, p<0.001).

CONCLUSION

The PA can be visualized in almost all echocardiographic exams, especially when it is dilated. A view showing the pulmonary trunk should be included in every routine TTE. An increased PA:A should raise suspicion for PH and prompt further evaluation and follow-up examinations of these patients.